15. E. E. Sickbert-Bennett, L. M. Dibiase, W. Schade, E. S. Wolak, D. J. Weber, and W. A. Rutala, “Reduction of Healthcare-Associated Infections by Exceeding High Compliance with Hand Hygiene Practices,” Emerging Infectious Diseases 22, no. 9 (2016): 1628–30.
16. Megan McArdle, The Up Side of Down: Why Failing Well Is the Key to Success (New York: Penquin Books, 2015).
17. McArdle, The Up Side of Down, 103.
18. R. M. Klevens, J. R. Edwards, C. L. Richards, T. C. Horan, R. P. Gaynes, D. A. Pollock, and D. M. Cardo, “Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002,” Public Health Reports 122 (2007): 160–66.
19. Chip Heath and Dan Heath, Made to Stick: Why Some Ideas Survive and Others Die (New York: Random House, 2007).
Chapter 4
1. Sanjaya Kumar, Fatal Care: Survive in the U.S. Health System (Minneapolis, MN: IGI Press, 2008).
2. John R. Clarke, Janet Johnston, and Edward D. Finley, “Getting Surgery Right,” Annals of Surgery 246, no. 3 (2007).
3. Comment on never events: for a complete list of “never events,” see http://psnet.ahrq.gov/resource.aspx?resourceID=3643.
4. Kim Smiley to Patient Safety Blog, January 16, 2014, http://www.patient-safety-blog.com/2014/01/16/the-willie-king-case-wrong-foot-amputated/.
5. Tatiana Morales, “Switched before Birth,” 2004, http://www.cbsnews.com/news/switched-before-birth/.
6. J. Martinez, “What a Mess, Baby,” Daily News, March 22, 2007.
7. Carol Kopp, “Anatomy of a Mistake,” 2003, http://www.cbsnews.com/news/anatomy-of-a-mistake-16-03-2003/.
8. David C. Ring, James H. Herndon, and Gregg S. Meyer, “Case 34-2010,” New England Journal of Medicine 363, no. 20 (2010).
9. P. G. Shekelle et al., “Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices,” in Comparative Effectiveness Review No. 211, ed. Southern California-RAND Evidence-Based Practice Center (Rockville, MD: Agency for Healthcare Research and Quality, 2013).
10. P. F. Stahel et al., “Wrong-Site and Wrong-Patient Procedures in the Universal Protocol Era: Analysis of a Prospective Database of Physician Self-Reported Occurrences,” Archives of Surgery 145, no. 10 (2010).
11. A. Gardner, “Surgery Mix-Ups Surprisingly Common,” 2010, http://www.cnn.com/2010/HEALTH/10/18/health.surgery.mixups.common/.
12. P. J. Pronovost and E. Vohr, Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out (New York: Penquin Group, 2010).
13. Thomas G. Weiser et al., “An Estimation of the Global Volume of Surgery: A Modelling Strategy Based on Available Data,” The Lancet 372, no. 9633.
14. A. Gawande, The Checklist Manifesto: How to Get Things Right (New York: Metropolitan Books, 2009).
15. Associated Press, “Trail of Errors Led to 3 Wrong Brain Surgeries,” 2007, http://www.nbcnews.com/id/22263412/ns/health-health_care/t/trail-errors-led-wrong-brain-surgeries/#.WBUSquErJTY.
16. “Trail of Errors Led to 3 Wrong Brain Surgeries: Surgeons’ Ego at R.I. Hospital May Have Led to Carelessness, Study Says,” 2007, http://www.nbcnews.com/id/22263412/ns/health-health_care/t/trail-errors-led-wrong-brain-surgeries/#.VedHytNVhBc.
17. Hemadri Makani to Success in Healthcare, September 14, 2012, http://successinhealthcare.blogspot.com/2012/10/mark-site-campaign.html.
18. Comment on operating room conversation: This conversation reportedly occurred in a hospital in India, but a version of this has played out countless times in American hospitals and the world over.
19. World Health Organization, “WHO Guidelines for Safe Surgery (First Edition)” (Geneva, Switzerland: World Health Organization, 2008).
20. R. L. Brooks, “Are You Using the Universal Protocol Yet?” AAOS Now 9, no. 5 (2015), http://www.aaos.org/news/bulletin/marapr07/clinical6.asp.
21. Comment regarding presurgical markings: The Universal Protocol makes accommodations for the situations in which a site marking is not anatomically or technically possible (e.g., minimal access procedures involving a lateralized organ) or when it would be undesirable to use (premature infants for whom a mark could cause a permanent tattoo), or when a patient refuses to have their body marked.
22. Martin A. Makary et al., “Operating Room Briefings and Wrong-Site Surgery,” Journal of the American College of Surgery 204, no. 236–43 (2007).
23. Gawande, The Checklist Manifesto.
24. National Public Radio, “Atul Gawande’s ‘Checklist’ for Surgery Success,” Morning Edition (2010), http://www.npr.org/templates/story/story.php?storyId=122226184.
25. National Public Radio, “Atul Gawande’s ‘Checklist’ for Surgery Success,” 157.
26. Brooks, “Are You Using the Universal Protocol Yet?”
27. Gawande, The Checklist Manifesto, 160–61.
28. National Public Radio, “Atul Gawande’s ‘Checklist’ for Surgery Success.”
29. National Public Radio, “Atul Gawande’s ‘Checklist’ for Surgery Success,” 151.
30. Mary Blanco, John R. Clarke, and Denise Martindell, “Wrong Site Surgery Near Misses and Actual Occurences,” AORN Journal 90, no. 2 (2009); John R. Clarke, “The Use of Collaboration to Implement Evidence-Based Safe Practices,” Journal of Public Health Research 2, no. 150–53 (2013).
31. John R. Clarke, “Is Your Office Helping You Prevent Wrong Site Surgery?” Bulletin 99, no. 4 (2014), http://bulletin.facs.org/2014/04/is-your-office-helping-you-prevent-wrong-site-surgery/.
32. Jesse M. Pines et al., “Procedural Safety in Emergency Care: A Conceptual Model and Recommendations,” Joint Commission Journal on Quality and Patient Safety 38, no. 11 (2012).
33. Clarke, Johnson, and Finley, “Getting Surgery Right.”
Chapter 5
1. Sorrel King, Josie’s Story: A Mother’s Inspiring Crusade to Make Medical Care Safer (New York: Atlantic Monthly Press, 2009).
2. King, Josie’s Story.
3. King, Josie’s Story.
4. Maureen Maurer et al., “Guide to Patient and Family Engagement: Environmental Scan Report,” in AHRQ Publication No. 12-0042-EF (Rockville, MD: Agency for Healthcare Research and Quality, 2012).
5. Paul L Aronson et al., “Impact of Family Presence During Pediatric Intensive Care Unit Rounds on the Family and Medical Team,” Pediarics 124, no. 4 (2009).
6. Tom Delbanco et al., “Healthcare in a Land Called PeoplePower: Nothing About Me without Me,” Health Expectations 4, no. 3 (2001).
7. National Patient Safety Foundation, “National Agenda for Action: Patients and Families in Patient Safety—Nothing About Me, without Me,” https://c.ymcdn.com/sites/www.npsf.org/resource/collection/ABAB3CA8-4E0A-41C5-A480-6DE8B793536C/Nothing_About_Me.pdf.
8. Wenjun Zhong et al., “Age and Sex Patterns of Drug Prescribing in a Defined American Population,” Mayo Clinic Proceedings, Mayo Clinic 88, no. 7 (2013).
9. Medical News Today, “Record 4.02 Billion Prescriptions in the United States in 2011,” MNT (2012), http://www.medicalnewstoday.com/releases/250213.php.
10. Consumer Healthcare Products Association, “Statistics on OTC Use,” 2015, http://www.chpa.org/marketstats.aspx.
11. J. Lazarou, B. H. Pomeranz, and P. N. Corey, “Incidence of Adverse Drug Reactions in Hospitalized Patients: A Meta-Analysis of Prospective Studies,” JAMA 279, no. 15 (1998).
12. John Sandars and Gary Cook, ABC of Patient Safety (Malden, MA: Blackwell Publishing, 2007).
13. Centers for Disease Control and Prevention, “Therapeutic Drug Use,” FastStats (2015), http://www.cdc.gov/nchs/fastats/drug-use-therapeutic.htm.
14. David C. Radley et al., “Reduction in Medication Errors in Hospitals Due to Adoption of Computerized Provider Order Entry Systems,” Journal of the American Medical Informatics Association 20, no. 3 (2013).
15
. Dianne E. Tobias and Mark Sey, “General and Psychotherapeutic Medication Use in 328 Nursing Facilities: A Year 2000 National Survey,” Consultant Pharmacist 16, no. 1 (2001).
16. Dan Mendelson et al., “Prescription Drugs in Nursing Homes: Managing Costs and Quality in a Complex Environment,” in NHPF Issue Brief (National Health Policy Forum, 2002).
17. T. J. Moore, M. R. Cohen, and C. D. Furberg, “Serious Adverse Drug Events Reported to the Food and Drug Administration, 1998–2005,” Archives of Internal Medicine 167, no. 16 (2007).
18. Jill Van Den Bos et al., “The $17.1 Billion Problem: The Annual Cost of Measurable Medical Errors,” Health Affairs 30, no. 4 (2011).
19. Institute of Medicine, “Preventing Medication Errors” (Washington, DC: National Academy Press, 2006).
20. Philip Aspden et al., Preventing Medication Errors (Washington, DC: National Academies Press, 2007).
21. J. D. Birkmeyer and J. B. Dimick, “Leapfrog Safety Standards: Potential Benefits of Universal Adoption,” in Fact Sheet: Computerized Physician Order Entry (The Leapfrog Group, 2014).
22. D. W. Bates et al., “Effect of Computerized Physician Order Entry and a Team Intervention on Prevention of Serious Medication Errors,” Journal of the American Medical Association 280 (1998).
23. Daniel R. Levinson, “Adverse Events in Skilled Nursing Facilities: National Incidence among Medicare Beneficiaries” (Washington, DC: Department of Health and Human Services, 2014).
24. D. W. Bates et al., “The Costs of Adverse Drug Events in Hospitalized Patients,” JAMA 277, no. 4 (1997).
25. Jonathon Halbesleben et al., “Rework and Workarounds in Nurse Medication Administration Process: Implications for Work Processes and Patient Safety,” Health Care Management Review 35, no. 2 (2010): 125.
26. L. L. Leape et al., “Systems Analysis of Adverse Drug Events,” JAMA 274, no. 1 (1995).
27. Robert K. Michaels et al., “Achieving the National Quality Forum’s ‘Never Events’: Prevention of Wrong Site, Wrong Procedure, and Wrong Patient Operations,” Annals of Surgery 245, no. 4 (2007).
28. Matthew Grissinger, “The Five Rights: A Destination without a Map,” Pharmacy and Therapeutics 35, no. 10 (2010).
29. T. A. Brennan et al., “Incidence of Adverse Events and Negligence in Hospitalized Patients: Results from the Harvard Medical Practice Study,” New England Journal of Medicine 324 (1991).
30. The Leapfrog Group, “Fact Sheet: Computerized Physician Order Entry,” http://www.leapfroggroup.org/media/file/FactSheet_CPOE.pdf.
31. Leah Binder and William H. Finck, “Results of the 2013 Leapfrog Hospital Survey: Executive Summary” (2015), http://www.leapfroggroup.org/sites/default/files/Files/2013LeapfrogHospitalSurveyResultsReport.pdf.
32. Castlight Health, “Results of the 2014 Leapfrog Hospital Survey: Computerized Physician Order Entry,” 2015.
33. The Leapfrog Group, “Factsheet: Bar Code Medication Administration,” http://www.leapfroggroup.org/sites/default/files/Files/BCMA_FactSheet.pdf.
34. Larry Mercer, Philip Felt, and Noell R. Snider, “Getting the Most Out of Your Epic EMR Training Program,” White Paper (2012), http://divurgent.com/wp-content/uploads/pdf/EpicEMRTrainingProgram.pdf.
35. Del Beccaro, H. E. Jeffries, M. A. Eisenberg, and E. D. Harry, “Computerized Provider Order Entry Implementation: No Association with Increased Morality Rates in an Intensive Care Unit,” Pediatrics 118, no. 1 (2006).
36. CBS, “Hospital Agrees to Pay $8.25M in Baby’s Death from Overdose,” CBS Chicago (2012), http://chicago.cbslocal.com/2012/04/05/babys-death-yields-record-settlement-of-more-than-8m/.
37. D. Dowell, T. M. Haegerich, and R. Chou, “CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016,” JAMA 315, no. 15 (2016).
38. CBS, “Hospital Agrees to Pay $8.25M in Baby’s Death from Overdose.”
39. Bibb Latane and Judith Rodin, “A Lady in Distress: Inhibiting Effects of Friends and Strangers on Bystander Intervention,” Journal of Experimental Social Psychology 5 (1969).
40. Megan McArdle, The Up Side of Down: Why Failing Well Is the Key to Success (New York: Penquin Books, 2015).
41. Department of Education, “Human Performance Improvement Handbook” (Washington, DC: U.S. Depatment of Energy, 2009).
42. Whatis.com, “Workaround,” http://whatis.techtarget.com/definition/workaround.
43. Leslie Kirle, “Errors in Transcribing and Administering Medications,” Safety First Alert (2001), http://www.macoalition.org/documents/SafetyFirst3.pdf.
44. “Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety,” Journal of the American Medical Informatics Association 15, no. 4 (2008).
45. Aaron S. Kesselheim et al., “Clinical Decision Support Systems Could Be Modified to Reduce ‘Alert Fatigue’ While Still Minimizing the Risk of Litigation,” Health Affairs 30, no. 12 (2011).
46. Heleen van der Sijs et al., “Overriding of Drug Safety Alerts in Computerized Physician Order Entry,” Journal of the American Medical Informatics Association: JAMIA 13, no. 2 (2006).
47. Institute for Safe Medication Practices, “The Five Rights: A Destination without a Map,” https://www.ismp.org/newsletters/acutecare/articles/20070125.asp.
48. Grissinger, “The Five Rights: A Destination without a Map.”
49. Institute for Safe Medication Practices, “The Five Rights.”
50. World Health Organization, “Patient Identification,” Patient Safety Solutions 1, Solution 2 (2007), http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution2.pdf.
51. Maurer et al., “Guide to Patient and Family Engagement.”
52. National Patient Safety Agency, “Wristbands for Hospital Inpatients Improves Safety,” http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=60032.
53. Institute for Safe Medication Practices, “Independent Double-Checks: Undervalued and Misused,” Institute for Safe Medication Practices, https://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=51.
54. PR Newswire, “Boston Medical Center Teams up with Rhode Island Hospital, CVS Health to Address Use of Pharmacy-Based Naloxone to Combat Opioid Addiction and Overdoses,” news release, 2015, http://www.prnewswire.com/news-releases/boston-medical-center-teams-up-with-rhode-island-hospital-cvs-health-to-address-use-of-pharmacy-based-naloxone-to-combat-opioid-addiction-and-overdoses-300124914.html.
55. Carolyn Weems, “Fighting Heroin in Virginia Beach,” Virginian-Pilot, November 20, 2015.
56. Margaret Kavanagh, “Virginia Beach School Board Member Shares Painful Memories of Daughter’s Overdose,” WTKR, July 8, 2015.
57. Sam Quinones, Dreamland: The True Tale of America’s Opiate Epidemic (Dexter, MI: Bloomsbury Press, 2015).
58. Substance Abuse and Mental Health Service Administration, “Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings,” ed. Substance Abuse and Mental Health Service Administration (Rockville, MD, 2014).
59. Centers for Disease Control and Prevention, “New Research Reveals the Trends and Risk Factors Behind America’s Growing Heroin Epidemic,” news release, July 7, 2015, 2015, http://www.cdc.gov/media/releases/2015/p0707-heroin-epidemic.html.
60. Gretchen LeFever Watson, Andrea Powell Arcona, and David O. Antonuccio, “The ADHD Drug Abuse Crisis on American College Campuses,” Ethical Human Psychology and Psychiatry 17, no. 1 (2015); Gretchen LeFever Watson et al., “Shooting the Messenger: The Case of ADHD,” Journal of Contemporary Psychotherapy 44, no. 1 (2014); Gretchen LeFever Watson, “The Deadly Dangers of ADHD Drugs,” Virginian-Pilot, October 2, 2016.
61. United Nations Office on Drugs and Crime, “Word Drug Report 2012,” http://www.unodc.org/unodc/en/data-and-analysis/WDR-2012.html.
62. Alexandra Robbins, The Nurses: A Year of Secrets, Drama, and Miracl
es with the Heroes of the Hospital (New York: Workman Publishing Company, Inc., 2015).
63. Patricia Borns, “Investigation: Addicted Nurses Steal Patients’ Drugs: In Virginia, a Broken System of Employers and State Programs Allow It to Continue,” Investigation: Addicted Nurses (2016), http://www.newsleader.com/topic/997446b5-cea1-4493-b989-548be165cc47/addicted-nurses/.
64. Donna Tartt, The Goldfinch (New York: Little, Brown and Company, 2013).
65. Mark Herring, “An Epidemic of Opioid Death,” Virginian-Pilot, September 21, 2016.
66. Kavanagh, “Virginia Beach School Board Member Shares Painful Memories of Daughter’s Overdose.”
67. Borns, “Investigation: Addicted Nurses Steal Patients’ Drugs.”
68. Centers for Disease Control and Prevention, “Therapeutic Drug Use.”
69. Dowell, Haegerich, and Chou, “CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016.”
Chapter 6
1. National Patient Safety Foundation, “Safety Is Personal: Partnering with Patients and Families for the Safest Care” (Boston, MA: National Patient Safety Foundation, 2014).
2. Tejal K. Gandhi and Gregg S. Meyer, “United for Patient Safety: National Patient Safety Foundation Report 2014–2015” (Boston, MA: National Patient Safety Foundation, 2016).
3. Vikki Entwistle, Michelle M. Mello, and Troyen A. Brennan, “Advising Patients About Patient Safety: Current Initiatives Risk Shifting Responsibility,” Journal on Quality and Patient Safety 31, no. 9 (2005).
4. Vikki Entwistle, “Nursing Shortages and Patient Safety Problems in Hospital Care: Is Clinical Monitoring by Families Part of the Solution?” Health Expectations 7 (2004).
5. Joint Commission on Accreditation of Healthcare Organizations, “Speak Up: Help Prevent Errors in Your Care,” in JCAHCO, ed. Joint Commission on Accreditation of Health Care Organizations (2003).
6. G. Van Kanegan and M. Boyette, How to Survive Your Hospital Stay: The Complete Guide to Getting the Care You Need—and Avoiding Problems You Don’t (New York: Fireside, 2003).
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